Respiratory rate = 40 under 1 yr, 30 between 2 - 5, and 20 over 12
Systolic Blood pressure = 70 - 90 under 1 year, 80-100 between 2 and 5, 90 - 110 between 5 and 12, and 100-120 over 12. Arch Dis Child. 2007 Apr;92(4):298-303.
In other words, Range of 20 @ every age, increasing by 10 in each group, with a Max of 100 @ 2-5, and a minimum of 100 @ 12+.
Axis @ birth 60-180, @ 1 yr 10-100, @ >1yr 30-90, (prems have LESS Rt dominance!)
RVH defined as: Dominant RV1 +/- Q after 1 yr, Upright TV1 over 1 week and under 7 yr, SV6 over 15mm if under 1yr or over 5mm if over 1 yr.
Brugada syndrome - genetic arrhythmia. Persistent or intermittent right sided ST elevation and RBBB, leading to VF and sudden death.
QTc is normally under 0.490 up to 6 months, or 0.425 if over 6 months. Calculation = QT/SQR(RR), where QT is time from beginning of Q to end of T. Easiest way to calculate it is to count small squares: QTc is then QT/5 divided by SQR(RR) (where default is 25mm/sec).
PR 80-160ms, QRS less than 75ms, RV1 less than 20-26mm (trough at 1 year), SV6 less than 10mm at birth falling to 4 mm at 10 year.
Autoimmune hx - arthritis, psoriasis, IBD, liver disease, vitiligo, thyroid.
Pendular vs jerk? Horizontal, vertical or rotatory? Head turning or torticollis (develops with severe nystagmus, an attempt to find position of least movement)?
Congenital pendular nystagmus is commonly associated with ocular and visual defects; it typically occurs with albinism, aniridia, achromatopsia, congenital cataracts, congenital macular lesions, congenital optic atrophy, and high refractive errors.
Congenital jerky nystagmus is characterized by horizontal jerky oscillations worse in one direction of gaze than in the other, with the jerk toward the direction of gaze.
Acquired nystagmus requires prompt and thorough evaluation. Worrisome pathologic types are gaze-paretic (Eyes jerk back to maintain eccentric gaze) or gaze-evoked (Jerk nystagmus in direction of gaze) suggesting cerebellar, brain stem, or cerebral disease. Mechanisms of ocular motor stability undergo a period of postnatal maturation, eg at 3 to 8 months, during which pendular nystagmus can occur, but also during which nystagmus may disappear. Scary!
Opsoclonus = spontaneous, nonrhythmic, multidirectional, chaotic movements of the eyes. The eyes appear to be in agitation, with bursts of conjugate movement of varying amplitude in varying directions. Most often associated with encephalitis. It may be the first sign of neuroblastoma. Else hydrocephalus, diseases of brain stem and cerebellum.
Other unusual patterns incl:
Other causes of acquired include Coeliac disease (more common in people with unexplained neurological disorder incl ataxia), Carbamazepine overdose.
Arch 1993, 69:102
Use a small aperture size for a small (undilated) pupil. The vertical slit beam helps discern concavity and convexity eg a raised optic nerve head (papilloedema) or a retinal lesion (eg retinoblastoma). The green beam makes vascular abnormalities and haemorrhages more obvious.
The normal "red reflex &qout; can actually be orange, or a bit yellow. It may not be one solid colour, especially if the patient has a refractive error. However, the reflex should be equal in both eyes.
If struggling, try again after dilating drops.
The corneal light reflex assesses ocular alignment. The reflection should lie in the same position on each cornea relative to the pupil: normally, central or just nasal of centre. Do not look through the ophthalmoscope, just use it as a light source. If an eye is turned inward (esotropia), there will be a lateral displacement of the light reflex in the turned eye, and vice versa for exotropia (NB If the child’s gaze is wandering, then the light reflex may be off-centre). Pseudoesotropia is the illusion of crossed eyes in an infant or toddler when in reality there is no strabismus present - this optical illusion is influenced by epicanthal folds and lid contour. Can be distinguished from true esotropia by symmetric and central corneal light reflexes.
Check for afferent pupillary defect using the swinging flashlight test.
Holmes Adie pupil – dilated, and slow to constrict to light, in association with absent deep tendon reflexes! Sometimes excessive sweating. Sporadic, associated with females, Sjogrens, migraine. Use pupillary constrictors if vision a problem.
Conjunctiva and skin - you can use the ophthalmoscope to look around the eye too.
For examination of the fundus, make it easier by dimming lighting or by dilation. If undilated, the smaller round light may be better as there will be less reflection from the iris. Tell the patient to fixate on a distant target (to minimize pupillary constriction which accompanies near viewing). Avoid obstructing the eye which is not being examined (else the gaze wanders). Be patient, keep a fixed position just off to the side of the patient with the retina in focus. Eventually the optic nerve will flash into view. The optic nerve can be located by following the arrows formed by vascular bifurcations. The optic cup is the central area of the optic disc and the cup-to-disc ratio should be noted (normal 0.3 or less). The normal optic nerve is yellow-orange or pink with sharp margins. The color of the fundus varies relating to skin pigmentation, varies widely. The macula is normally located about two disc diameters temporal to the edge of the optic nerve. At the center of the macula is a small dark area, marking the location of the central fovea. In children, the retina is shiny and the macula may be delimited by a smooth, shiny reflex reflecting the healthy superficial retinal nerve fibers on its surface. Ask the patient to look directly at the light.
Pediatric Emergency Care Volume 17(3) June 2001 199-204
Investigate any child with osmotic symptoms or strong family history with random glucose (cap or venous) >7.8. WHO criteria - Random over 11.1 + symps/FH, else fasting >7.
Admission hypoalbuminaemia is common in critical illness, but is not an independent predictor of mortality. However, failure to correct the anion gap for albumin may underestimate the true anion gap, producing error in the interpretation of acid-base abnormalities (each g/l of albumin contributes a charge of 0.25 mEq/l)
Ammonia above 200 is suspicious and should be repeated immediately, with or without encephalopathy. Lower values with encephalopathy may be found in metabolic disorder. Blood should be free flowing, without haemolysis, with minimum of stasis (eg tourniquet) and muscular activity in limb.
A few caveats. Measuring urine electrolytes assumes normal tubular function, so renal impairment or renally active drugs esp frusemide will confuse. Urine osmolality in SIADH should be inappropriately high but may not be maximal; alternative diagnosis may be reset osmostat, where osmolarity increases with water load but hyponat persists) - seen with tumours & neuro disorders eg agenesis corpus callosum.
If sodium restricted, eg renal/cardiac patient, urine values may be low and diagnosis may be missed.
Manage SIADH by fluid restriction. Frusemide useful: shifts more water than sodium. In emergency eg hyponatraemic seizures, give 3% saline (danger of increasing ECF compartment, so enhancing sodium losses in kidney). Aim to increase plasma sodium by 10mmol/L, so calculate deficit (use a factor of 0.6x body weight) then give half over an hour. Then give rest more slowly eg replacing urine output.
Beware central pontine myelinosis. Most likely in prolonged hyponatraemia (eg 2+ days) with rapid correction. Develops 2-3 days after correction of hyponatraemia, with impaired consciousness, dysarthria and dysphagia. Progresses to affect limbs. Avoid by correcting max 10mmol per day.
Cerebral insult can cause salt wasting OR SIADH! So check weight, urine output and sodium.
Acute potassium depletion: give 1mmol/kg in 100 ml N/Saline @ 0.2mmol/kg/hr - recheck after 3 hr.
Deficiency - slow IV bolus (10mins) 0.2mmol/kg of 10% (ie dilute 50% MgSO4 1in5, dextrose or saline).
Paracetamol ingestion of under 150mg/kg does not require blood levels. A 4hr level of 1 is needed for treatment, unless high risk.
CarboxyHb under 10% asymptomatic, 10-50% symp, over 50% coma/fits.
Subsets is a EDTA sample. Gives you a break down of components: normally,
Lymphocyte proliferation and function are the same thing: they're exposed to a range of stimuli and responses measured. A control sample is usually required.
Do your blood gas to see whether respiratory and/or metabolic. Anion gap (Na + K - Cl - HCO3) helps reveal undeclared acids - normal 13-19 (teens!). Ketones would be one cause: dipstick the urine. Lactate would be another.
Urine gap = U.Na + U.k - U.Cl. This is the anion gap without the bicarb! Negative suggests bicarb wasting viz RTA type 1, positive suggests renal compensation, ie gut losses.
Hyperchloraemia can cause metabolic acidosis - usual scenario is excessive normal saline eg in flushes. Reducing TPN chloride to 2-3mmol/l rather than 5-7 to take into account saline flushes reduced incidence of neonatal metabolic acidosis cf controls. Journal of Parenteral and Enteral Nutrition, Vol. 12, No. 2, 159-161 (1988) pmid 3129591 . Strong ion theory of acid-base proposed by Stewart. Instead of the usual Henderson-Hasselbalch approach to acids and base dissociation, Stewart's theory states that pH in plasma is dependent not only on the pCO2 and any charge from weak acids, but also on the strong ion difference (SID). The SID is calculated as the charge difference between the cations Na+, K+, Ca2+, and Mg2+ and the anions Cl-, lactate. (A strong ion is defined as one that is almost completely dissociated at physiological pH). As Na+ and Cl- far outweigh the others, their ratio relative to one another largely determines the SID. The SID is usually about 40, but if a large amount of saline is given, this becomes nearer 0. Note tendency to give saline boluses for metabolic acidosis, to "improve perfusion". [Arch 2000. Pmid 11087291]
In most cases LP confirms or excludes bacterial meningitis, but there are a few exceptions discussed below. Gram staining reveals an organism in 68–80% of cases of meningitis, giving a rapid diagnosis and allowing appropriate choice of antibiotics. Culture gives information on antibiotic resistance, which is especially important in areas where antibiotic resistant pneumococci are prevalent. Obtaining CSF also allows identification of mycobacteria and fungi (particularly important in immunodeficiency or on an intensive care unit) which would not respond to empirical treatment. Enteroviral meningitis can easily be diagnosed by PCR (from CSF, throat or stool), which allows discontinuation of antibiotics and early discharge.
Reinsertion of the stylet before needle removal decreases the risk of headache. JAMA. 2006 Oct 25;296(16):2012-22
Contraindications are focal neurological signs incl pupils, falling conscious level, abnormal respiratory pattern. Avoid if cardiorespiratory compromise. Infection in the area of needle insertion or signs of a bleeding disorder are also said to be contraindications, but these are based on single case reports.
The concern is raised intracranial pressure, where LP might precipitate cerebral herniation. Signs are:
Unilateral herniation typically causes ipsilateral fixed dilated pupil and contralateral hemiparesis. Symptoms and signs of cerebral herniation occur in 4–6%, and this complication accounts for 30% of deaths. Can occur without LP, of course, but case series have shown a temporal association between lumbar puncture and herniation. CT scanning is NOT helpful in children with this clinical presentation; most children with bacterial meningitis and clinically suspected raised intracranial pressure have normal scans, and death from herniation following LP can occur despite having a normal CT scan. Difficulties arise because pupils may be dilated or unequal during or immediately after a seizure, and absent oculocephalic reflexes can be transiently suppressed. A prolonged persistence of pupillary dilatation and, more important, absence of reaction to light indicate the probability of herniation rather than postictal state.
The other reason for doing CT is to detect those with a different diagnosis. Meningeal enhancement post contrast suggests meningitis, but other diagnoses include tumour, abscess, or intracranial haemorrhage. These are more likely to show signs of herniation, and LP would be dangerous. This is particularly relevant when a patient is comatose/paralysed and difficult to assess.
If there is cardiorespiratory compromise, the danger is that excessive flexion of the trunk and neck during lumbar puncture may produce hypoxaemia esp in neonates. Normally can be avoided by preoxygenation. But if septic shock, probably sensible to defer LP until the next day. Even though cultures are likely to be negative (within two hours after IV antibiotics are given in meningococcal meningitis but up to six hours in pneumococcal), the cellular and biochemical changes remain in cerebrospinal fluid up to 44–68 hours after the start of antibiotic treatment. This information crucial when there is a differential diagnosis of cerebral malaria (cannot be differentiated from meningitis clinically) and useful for deciding on duration of treatment. PCR and latex tests also useful for Meningococcus, Pneumococcus, and Haemophilus even after antibiotics: meningococcal PCR of CSF obtained at a delayed lumbar puncture has a sensitivity of 81%.
Although in theory an open fontanelle should prevent raised intracranial pressure and coning, there is evidence that exceptions occur (Dev Med Child Neurol. 2000 Jul;42(7):462-9. PMID 10972418).
In the UK at present empirical treatment with a third generation cephalosporin alone is likely to be adequate. However, in countries where there is pneumococcal resistance to cephalosporins, vancomycin should be added. Increasing antibiotic resistance makes culturing the causative organism essential.
Blood culture and/or PCR may help esp:
Traditional teaching is that young infants with meningitis may not have signs of meningism. This is based on a small study from 1969 where HIb was the causative organism in all cases. The rate of bacterial meningitis causing febrile seizures is very low, and is likely to be falling as a result of immunisation vs Hib, Men C and Pneumococcus. Carroll and Brookfield’s review suggest that the probability of bacterial meningitis presenting as fever and seizure is 0.4–1.2%. Signs of meningitis (meningism, irritability, lethargy, bulging fontanelle) are usually present but some cases have been described where signs were absent, and indeed where initial CSF was normal! Extrapolation of incidence data suggests that over 200 LPs would have to be performed in infants with febrile convulsion and no signs of meningitis to detect 1 case of meningitis. Children with meningitis but no meningism either have "complicated" seizures (prolonged, partial, or multiple) or worrying histories suggestive of meningitis (unwell for three days or more, vomiting or drowsy at home, seen by a doctor in the previous 48 hours). Children with simple febrile convulsions and no symptoms or signs of meningitis are highly unlikely to have bacterial meningitis.
AI Riordan, AJ Cant; Arch Dis Child 2002;87:235-237 PMID ; Carroll, Brookfield; Arch Dis Child 2002;87:238-240 PMID 12193441
PEDIATRICS Vol. 103 No. 6 June 1999, pp. 1284-1286
Adequate inspiration is 6 ribs visible anteriorly or 9 ribs posteriorly - trachea should be straight (elastic). To assess lung volume, look at rib spacing and mediastinal shift (1/3 to right, 2/3 to left) rather than diaphragm height. Turning the film upside down helps for some reason!
Atelectasis due to obstruction by foreign object takes 18-24 hrs to develop if breathing air (time for resorption) but only seconds if breathing 100% O2 eg in theatre. Air bronchogram means non obstructive collapse/consolidation as it reflects persisting air (eg surfactant loss).
Vessles should be easily visible within 2/3 of lung space from hilum, faintly visible beyond that (if not, then air trapping etc). Tapering and branching in nature.
Don't forget pneumothorax - loss of vessels, pleural line. If not under tension, then there should be loss of volume (due to loss of intrapleural negative pressure) - if there isn't loss of volume then beware early tension.
Look for clearly demarcated diaphragms (except behind heart) and clearly demarcated mediastinal margins.
Differentiation of bacterial vs viral - dense consolidation without bronchograms suggests bacterial. Ground glass suggests viral. (Plus CRP >80 gives PPV of 75% for bacterial) Thorax 2002 57:438, Virkki
The Thymus is commonly seen under 3yrs, and can sometimes be seen up to the age of 5. It changes size dramatically in response to infection, initially shrinking then recovering! It is usually found in the upper anterior mediastinum, but can extend down to the diaphragm. Ectopic tissue is sometimes found. The 2 lobes can be of quite different size. Defining characteristics:
If in doubt, do lateral.
Any infection causes a degree of persistent bronchodilatation so allow 3-6 months before diagnosing bronchiectasis.
Cancer risk from a modern CT (multidetector) is less than 1 in 1000.
Intramural gas seen in NEC, immunocompromised children with rota/adeno, C. diff, CMV. Presumably combination of mucosal injury by infection or systemic disease/drugs, increased luminal pressure (eg coughing, lots of chronic resp adult cases), bacterial gas production. High flow O2 works.
As intussusception progresses, earliest radiographic evidence includes an absence of air in the right sided quadrants and a right upper quadrant soft tissue density (25-60% of patients). These findings are followed by small bowel obstruction. If the distention is generalized and the air-fluid levels also are present in the colon, the findings more likely represent acute gastroenteritis than intussusception.
Football sign is the appearance of massive pneumoperitoneum on a supine AXR. Large oval radiolucency distends the whole abdomen (most obvious at edges of peritoneum) and a well-defined vertical linear opacity is seen in the upper abdomen, just to right of the midline (representing the seam of an American football). This is the falciform ligament. The football sign is most commonly seen in infants, secondary to NEC, volvulus, Hirschsprungs or other obstruction).
Optic nerve diameter over 4.5 was 100% sens and spec for RICP (n=156 children). Journal of Ultrasound in Medicine. Vol. 24(2)(pp 143-147), 2005
Useful for benign intracranial hypertension? Excellent correlation between LP opening pressure and US findings. Journal of Pediatrics. Vol. 131(5)(pp 734-740), 1997.
Lucency in metaphysis may be marrow infiltration in leukaemia, Brodie's abscess or Langerhans' histiocytosis. Moth eaten appearance and onion skin periosteal reaction suggests tumour or infection.
Fracture or ossification centre? If painful then it's a fracture! CRITOL criteria for ossification centres in wrist.
Bladder capacity is = (Age +1) x 30 (ml) max 390ml.
Incomplete bladder emptying cannot be diagnosed on a single post-void residual urine on ultrasound, due to significant intra-individual variability. Two post-void residual urine tests are recommended; larger volumes are seen if the bladder has been over distended (eg initial volume greater than 115% of expected), and in younger children. Greater than 20 ml is more specific than 10% bladder capacity. J urology 2009 (182):1933
See OPD for more on enuresis.
Has been described as one of the most abused investigations in clinical medicine. Spikes with or without slow waves and, to a lesser extent, sharp waves are the electrical hallmark of epilepsy. However, at least 1% of adults and 3.5% of children who do not have epilepsy will demonstrate spikes on a routine awake EEG! And 50% of patients with epilepsy have no interictal abnormalities on EEG.
If the interictal EEG is normal (including photosensitivity and hyperventilation provocation), then the options are to do sleep-deprived or 24hr. Sleep-deprived is particularly good for symptoms in the night; patient is woken in the early hours then allowed to fall asleep in the EEG lab.
Nose - Parent should hold child, seal mouth with their mouth and blow! Smell is terrible if foreign body has been there for some time.
Vapo-coolant spray reduces pain due to intravenous cannulation in children: RCT. Improved success rate of first attempt! CMAJ. 2008 Jul 1;179(1):31-6. PMID: 18591524
Softsense forearm blood glucose tester mostly painless.
As a general rule, dry powder inhalers can be used from the age of 7yrs. Require a decent suck, but no coordination. Good for through the day use, not good for major exacerbations when you don't have enough puff.
Aerochamber fits Pulmicort & salbutamol. Preferred by some who struggle with bigger spacer ie Volumatic.
See UTI for discussion of NICE 54. Very little data on the accuracy of clinical investigations for the diagnosis of UTI.
Health Technology Assessment (Winchester, England). 10(36):iii-iv, xi-xiii, 1-154, 2006 Oct.
Microscopic haematuria: + = 5-10 rbc, +++ = 500. Nephritic? ie proteinuria, oedema. If unwell, do glomerulonephritis (GN) screen else recheck at 1 week. If urinalysis otherwise normal, consider trauma (CT if >50 rbc/hpf), stones (USS, biochemistry), tumour, UTI. If GN screen shows normal creatinine, BP, protein excretion then monitor. Anything else, refer. See Renal for macroscopic, recurrent.
++ is equivalent to 1g/L of proteinuria, +++ 3g/L, ++++ is over 20! False positives with alkaline or concentrated urine, or if testing delayed. False negative with dilute urine.
If nothing found then monitor.
Proteinuria in adults with renal disease is the best predictor of end stage renal failure. ACE inhibitors reduce proteinuria, decline in GFR and development of renal failure.
No difference in urinary cotinine between houses with no rules and those with less strict rules; banning smoking in the home causes a small but significant reduction.
Touch is sensitive (90%) but not specific (50%) for fever - so don't dismiss parental reporting entirely. J Trop Pediatr. 2008 Feb;54(1):70-3 PMID 18039678 Tympanic thermometer does not reliably correlate (wax? angle?) and misses about 1 in 8 fevers Acad Emerg Med. 2000 Sep;7(9):1061-4. PMID 11044005 (although NICE offers as option).
The quoted 1% risk of invasive bacterial disease in young children with unexplained fever presenting to hospital is almost certainly a considerable overestimate. The NICE guideline differentiates Red symptoms/signs that clearly indicated serious illness, whereas the Amber group includes the vast majority of children. And anyway, we know signs and symptoms other than classic neck stiffness etc fails to predict outcome; best predictor was "something is wrong" - hence most important primary care action is prompt clinical assessment by experienced clinician. BrJGP 2007;57:538, pmid 17727746
Under 3 months - if previously healthy, no evidence of focus, normal WCC then risk is minimal. Empirical treatment for the under 1 month, see Baraff. (Peds 97;100) Ambulatory care suggested by Dagan back in 1988 (J ped 112). With universal conjugate Pneumococcal vaccine, the chances of invasive bacterial infection are much less than they used to be. Remember that if fever has been of short duration eg under 12 hrs, inflammatory markers become less reliable. Pratt, Peds International 2007 PMID 17250502
Baraff now recommends that all febrile infants get full sepsis screen including LP. Between 1 and 3 months of age the rate of serious bacterial infection is much lower - if non-toxic looking (see below), use inflammatory markers only.
Over 3 months - fever greater than 39 predicts bacteraemia in 3% of kids before Prevenar (conj pneumococcal vaccine) - now more like 0.7%; but usually transient and not requiring antibiotics! Children vaccinated against Pneumococcus have 10% the risk of invasive pneumococcal disease. If non-toxic, and vaccinated, then urinalysis and urine culture. (Annals Emerg Med 2000;36)
NB even if a risk falls to 1%, the cumulative chance of getting at least 1 positive after 100 patients rises to 50%!
Lacour scoring system ("Laboratory-Score") based on CRP, PCT and urinalysis. Has sensitivity of 94%, spec of 81%. Would reduce incidence of antibiotic use from 65 to 40% but good enough? Lacour, PIDJ 2008 PMID 18536624
Convalescent serology for culture negative cases may reveal causative organism eg Flu, EBV, CMV, Parvo.
Hyperpyrexia (> 41.1.degC): 20% will have serious bacterial infection. Chronic underlying illness or diarrhoea increases the risk, rhinorrhoea or other viral symptom decreases it. Age, maximum temperature, and total white blood cell count were surprisingly not predictive of either bacterial or viral illness! (n=103). (Pediatrics. 118(1):34-40, 2006 PMID 16818546)
A systematic history and repeated, careful examination is the key to diagnosis. Measure and document the temperature during a period of close observation (beware factitious fever). If possible, stop all drugs. Antipyretics may add to the comfort of the child, and response to these drugs, particularly to NSAIDs may assist in the characterization of fever. But they may not do much for infection, may obscure the pattern of fever, and can occasionally be its cause. Investigate for common conditions presenting in an unusual way before thinking of rare causes of FUO, resist the temptation to work down lists of tests - be guided by the clues given in the history and examination. Unless the child is critically ill, do not treat empirically. If the diagnosis remains obscure, go back and take the history again, send the specimens again!
The most widely accepted definition of FUO is fever with documented temperatures of 38.3C on several occasions, persisting for more than 3 weeks, and uncertain diagnosis after intensive study during hospital admission for at least a week. However, this is used for adults, and with better, quicker diagnostic tests, and better imaging techniques, a FUO could reasonably be defined as the presence of fever for 8 days or more in a child in whom a careful thorough history and physical examination, and preliminary laboratory data fail to reveal a probable cause for the fever. There are reports of over 200 causes of FUO. Infection is the commonest cause in children in whom a diagnosis is eventually reached, amounting to around 40% of cases. 12-15% have collagen vascular disease. Malignancy is even less common (cf adults), chiefly leukaemia and lymphoma, 5-13% of cases.
| Infectious diseases - Bacterial |
| Brucellosis |
| Bacterial endocarditis |
| Liver abscess |
| Mastoiditis |
| Osteomyelitis |
| Pelvic abscess |
| Perinephric abscess |
| Pyelonephritis |
| Salmonellosis |
| Sinusitis |
| Subdiaphragmatic abscess |
| Tuberculosis |
| Infectious disease - Viral |
| CMV |
| Hepatitis |
| HIV |
| EBV |
| Infectious diseases - Other |
| Leptospirosis |
| Lyme disease |
| Q fever (dead animals) |
| malaria |
| syphilis |
| toxocariasis |
| Chlamydial |
| Tularaemia |
| Collagen vascular disease |
| Juvenile idiopathic arthritis |
| Systemic lupus erythematosus |
| Behcet's disease |
| Kawasaki disease |
| Sarcoid |
| Familial Mediterranean Fever - arthritis, serositis |
| Malignancy |
| Hodgkin disease |
| Leukaemia/lymphoma |
| Neuroblastoma |
| Diencephalic fever - usually with failure to thrive & vomiting. |
| Hepatoma |
| Atrial myxoma |
| Miscellaneous |
| Drug fever - usually after 2+ weeks broad spectrum antibiotics |
| Factitious fever - look for absence of tachycardia, rapid defervescence without sweating, absence of diurnal variation, normal rectal temperature |
| Familial dysautonomia |
| Ectodermal dysplasia |
| Crohn's disease |
| Periodic fever - see Immunology |
| Thyrotoxicosis |
| Cystic Fibrosis |
Maximum/minimum temperature, the method of measurement used, any association with location, or with time of day, and whether there are afebrile periods, and if so, how long they last. Some diseases have characteristic fever patterns, such as malaria (spikes every 2, 3 or 4 days depending on species) and juvenile idiopathic arthritis (big spikes with return to or below baseline). Weight loss, infectious contacts (TB), visitors from abroad (typhoid) and sexual contact. Blood transfusions, and exposure to needles (accidental or otherwise). Animal, bird and insect exposure. Pets (anybody's) - kittens spread bartonella (cat-scratch disease), farm visits, recreational pursuits and local surroundings. Animal or tick bites or scratches (Mediterranean Spotted Fever = Rickettsia coronae, tick bite on leg from scrub ?eschar). Foreign travel, local travel eg farmland. Unpasteurized milk (M bovis). Pica (worms, toxoplasmosis). Drugs (incl over-the-counter preparations, herbal/alternative remedies). The immunization record esp recent or omitted doses, BCG. Family history (immunodeficiency, familial Mediterranean Fever, or dysautonomia).
Child with Kawasaki's disease is utterly miserable, unable to play, whereas a child with systemic juvenile arthritis looks quite well except at the peak of fever. A child who looks completely well despite a documented high temperature may raise the suspicion of factitious fever.
In those with low or episodic fever, and normal ESR and haematocrit, less than 10% will have a definitive diagnosis.
The pace at which further investigations need to be performed will be dictated by the general condition of the patient. Resist the temptation to initiate empirical treatment unless fear that untreated disease is becoming life-threatening.
Arterial trace can show:
Ametop (amethocaine) is more effective than EMLA on metanalysis in terms of pain relief - but both are effective. No difference in ease of procedure.
For antibiotics, antivirals and antifungals, see Infection.
Paracetamol prolongs clearance of malaria, and time to total scabbing in chickenpox. So only give for symptomatic benefit, not as routine!
Cochrane did not find any evidence that drugs prevent febrile convulsions, but not much data. Not recommended. Tepid sponging probably does work, but is inferior to drugs.
Ibuprofen probably works a bit quicker, and lasts longer. Arch Peds Adol Metanalysis, 2004. PMID 15184213
Alternating paracetamol and ibuprofen was superior in an Israeli study and in a US study.Arch ped adol 2006 PMID 16461878, Clin peds 2008 PMID 18539869
Combined? PITCH found combination was more effective than either alone (reducing time with fever over a 24 hour period by 2.5 hours or more) although it did not work faster than ibuprofen alone. No specific benefit was found for symptoms although it was underpowered for subjective comfort. BMJ 2008 PMID 18765450 A linked cost benefit analysis suggested financial benefits to society for using the combination. On the other hand, use of the combination was associated with significant rates of medication errors and it could be argued that this risk outweighs the potential benefits.
Ibuprofen used as an antipyretic in febrile children with a past medical history of asthma is as least as safe as paracetamol and not likely to exacerbate asthma (Lesko, Peds 2002).
Total daily dose 0.5-1 U/kg (less for new diagnosis with residual secretion). For 3x a day regimen give 0.25U/kg as morning mixtard (or Humulin M3), 0.1 as tea time Novorapid, 0.15 as bed time Insulatard or Levemir/Lantus. For 4x a day regimen (more injections but more flexible in terms of meal times/sizes) give half total as basal bolus eg Levemir/Lantus, divide the rest as Novorapid at mealtimes.
Novorapid is synthetic ultrashort acting insulin. Not suitable for IV infusions!
Mixtures of medium and short acting insulins are used for simple regimes eg BD or TDS dosing. Only 30/70 mix available now. Separates on standing so agitate.
Lantus (=glargine)/Levemir (=detemir) are 24hr insulins (but some patients metabolize differently and need BD dosing) - no benefit in terms of complications, but less hypos. Lantus may last a little longer than Levemir.
Sick day dose is 1/7 total daily dose as Novorapid (give 2hrly), or 1/5 total daily dose given as Actrapid (4 hrly).
Some pens do 1/2u per click. Do a 2u test shot before each injection to prime needle and check function. Fridge only important for infants where 1 vial may last more than a month. Flexpens are preloaded, disposable.
For inflamed PEG sites - lyofoam, Inadine, Sofradex.
For perineum - Allevyn, Cavilon sealing spray.
Tacrolimus is superior to ciclosporin in improving graft survival (by 2%) and preventing acute rejection (by 12%) after kidney transplantation. The cosmetic side-effect profile is better, but it increases neurological and gastrointestinal side effects and also post-transplant insulin-dependent diabetes mellitus (by 5%). Tons of interactions!
MTX tabs 2.5 or 10mg, similar size/colour but different shape. Community pharmacists not keen to mix and match, to avoid confusion.
Lots of different devices:
Flixotide (fluticasone) is orange. About twice as strong as other steroids, but no specific advantage. High strength Becotide (beclometasone) is red (250), normal (100) is dark brown. Low strength is light brown (50). Qvar and Clenil Modulite are CFC-free versions (and only for over 12s) but not equivalent; Qvar is approximately twice as strong as Clenil. Asmanex (mometasone) is a twisthaler, only for over 12s and if first-line steroids have failed (200/400).
Children on high doses should have a Steroid Card.
Combinations: Serevent (salmeterol) is green; Seretide (salmeterol with fluticasone, 50/125 as an MDI else 100/250/500 Accuhaler) is purple. Symbicort (budesonide/formoterol) is red, comes as a turbohaler (100/6 or 200/6).
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